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A Foundation for Evidence-Driven Practice: A Rapid Learning System for Cancer Care - Workshop Summary
with standard protocols and “if we can get to the point where those 80 percent take about 30 percent of our effort, then we have a lot of time to deal with the people that need customized care.”
KP has about 200 oncologists working in at least 40 sites. To create more systematic and less variable care, the system brought together a group of its oncologists, nurses, and pharmacists from a variety of different settings to develop more than 300 standard protocols for chemotherapy and clinical trials. These protocols were evidence based, but can be personalized and modified to meet patient variability and individual needs. “We wanted to test the hypothesis that, if we do that, it will lead to appropriate variability rather than random variability for our practice population,” Dr. Wallace said.
All care is electronically documented, including not just what specific treatment is given, but its indication (e.g., whether it is curative, secondline, or palliative). To address safety concerns, there are processes built in to ensure that “when you order a drug, you have absolute confidence that it will be translated into an order that will be translated into a bar code that will correspond to the patient to whom you are giving the drug,” Dr. Wallace said. Providers are also alerted when they approach the near-maximum dose for chemotherapy, and the entire healthcare team can view a treatment plan simultaneously and enter pertinent information electronically.
Kaiser physicians are given regular reports of their cancer care and how it compares to their peers on various measures, such as hospitalization rates, clinical trial enrollments, et cetera. When there is variability within and between practices, the providers are encouraged to try to determine the cause of the variability and what best practices to follow within their office or clinic because, as Dr. Wallace noted, “if you are not using the data to facilitate that conversation, there is no learning. Rapid learning takes place both at the practice level and at the system level.” If there is variability in certain regions and/or practices, KP can focus retraining and education efforts in that area to address the discrepancy in care.
KP has just begun testing its new system for oncology care and found that between 63 and 84 percent of its standard treatment protocols were used without modification. “This means physicians can focus their time on customizing care so care is patient driven, not clinician driven,” Dr. Wallace said. Encouragingly, new developments in chemotherapy were rapidly translated in the system. Within just a week of its being published that lower-dose Avastin was as effective at treating colon cancer as high dose, that shift in treatment began diffusing through the practices that are a part of KP,